Mini Review
Voiding and Continence Problems after Radical Cystectomy and Orthotopic Neobladder in Women: A Mini-Review
Mohamed H Zahran and Bedeir Ali-El-Dein*
Department of Urology, Urology and Nephrology Center, Egypt
*Corresponding author: Bedeir Ali-El-Dein, Department of urology, Urology and Nephrology Center, Mansoura, Egypt
Published: 24 Oct, 2016
Cite this article as: Zahran MH, Ali-El-Dein B. Voiding and
Continence Problems after Radical
Cystectomy and Orthotopic Neobladder
in Women: A Mini-Review. Clin Oncol.
2016; 1: 1131.
Abstract
Orthotopic neobladder has become the standard of care after radical cystectomy in select women with muscle invasive bladder cancer. Proper understanding of the natural history of bladder cancer and functional anatomy of female urethra were the cause of its application in women. Continence and voiding problems are still the most bothering symptoms that affect a significant proportion of women. It adversely affects patients' health related quality of life. Proper patients' evaluation and identification of possible risk factors is mandatory before decision making in order to reduce the possible risk of continence trouble.
Introduction
More than 20 years ago, many centers started to provide bladder cancer female patients with
Urethral-Sparing Radical Cystectomy (USRC) with orthotopic urinary diversion (ONB) [1]. This did
not gain the rapid clinical acceptance as in men because of the previous believes that urethrectomy
is an integral part of cystectomy in female for many reasons. The argument was the possible risk of
urothelial tumour recurrence in the remaining urethra, the higher risk of complications including
fistula formation with the vagina and the possible high risk of incontinence and voiding problems.
With proper understanding of the anatomy of female urethra and continence mechanisms together
with vast researches that confirmed the oncological safety of urethral-sparing as long as absence of
bladder neck involvement by the tumour, this encouraged urologist to provide their patients with
urethral-sparing cystectomy and orthotopic neobladder (ONB) [2]. Currently, ONB has become the
standard of care after USRC in select women with bladder cancer [3]. It has been estimated that 80%
of men and 65% of women undergoing RC for bladder cancer are eligible for ONB [4]. Here we try
to emphasize on the functional outcome of ONB in women especially continence status after it has
been a common practice.
Evolution of urinary diversion in women
Since the first reported urinary diversion (UD) using segment of the bowel by Simon in 1852,
innovative surgeons have investigated for the best form of UD [5]. The evolution of urinary
diversion has developed along 3 paths: non continent cutaneous diversion (ileal loop and colonic
loop), continent cutaneous diversion and orthotopic urinary diversion to the native urethra [6].
Ureterosegmoidostomy is the oldest form of urinary diversion and it remained the diversion of
choice till the late 1950s, when Bricker refined and popularized the ileal loop conduit. It has become
the reliable and the standard type of diversion in 1990s to which other types of diversion were
compared [6]. The first attempt of ONB in human was performed by Lemoine in 1913. In this
technique the two ureters were implanted in the rectum. Then the rectal segment was isolated and
anastomosed to the urethra [5]. After that many advances in the techniques of ONB have been
achieved till it become the most reliable and popular technique in males.
The encouraging results of orthotopic diversion in male raise the interest in applying the
technique in women. However, this was not going on parallel with its application in men due to
two main reasons. First, the available data on the natural history of synchronous and metachronous
urethral involvement in Urothelial Carcinoma (UC) was limited before 1990. This is because
the lower incidence of the disease in women in comparison to men together with the believes
that the shorter female urethra is more close to the bladder neck and hence to the tumour. Thus
cystourtherectomy was the standard of care in women [2]. Second; a little was known about the
proper anatomical and functional features of female urethra and the settled disbelieves of the ability
of shorter female urethra to maintain continence after cystectomy [7].
Many studies have been performed to revise the pathological
features of UC specimens and the urethral involvement. These
provided a scientific base for clinical application of USRC and ONB
in women as long as there is no bladder neck involvement by the
tumour [2]. Also, at the same times, several studies were performed
to study the anatomical and functional behavior of female urethra
which proved the ability to maintain continence with preservation of
the distal two thirds of female urethra [7]. Now; we can confirm that
with proper patient selection and refinement of surgical techniques,
USRC and ONB in women has shown a comparable outcome to men.
Table 1
Table 1
Incidence of continence and viding problem after radical cystectomy and orthotopic diversion in women.
Anatomy of Female Urethra and Continence Mechanism
An important cause of considering ONB for men and not in
women was the believes that women would be unable to maintain
continence after ONB. Therefore, urethrectomy was considered
as an integral part of radical cystectomy in women [8]. This was
changed after proper understanding of female urethral anatomy and
continence mechanisms. In women, several factors can maintain
continence at rest and at increased intra-abdominal pressure. The
urethra is made of three functional structures that result in elastic,
dynamic conduit with mucosal coaptation. The mucosa is formed
of transitional epithelium with mucosal infoldings that allow
distinsibilty and excellent coaptation. A sub mucosal spongy tissue
made up of vascular networks. Surrounding the spongy tissue is
a thin musculofascial envelope. These three components create a
coaptive seal.
The female urethral sphincter is composed of smooth muscle
sphincter and striated muscle sphincter (EUS). The smooth muscle
sphincter is formed of inner longitudinal coat and a sparse outer
semicircular coat. It is supplied by autonomic nerve supply from pelvic
plexus composed mainly of cholinergic nerve endings and sparse
adrenergic nerve ending. The striated muscle sphincter encircles the
smooth muscle from the bladder base down to the perineum without
distinction from urogenital diaphragm. It is more condensed around
mid-urethra providing high pressure zone. It is innervated from below
by the somatic fibers from pudendal nerve. The striated musculature
(EUS) provides resting urethral tone as well as an involuntary reflex
contraction in response to stress that increases coaptation. Adequate
urethral length is essential to provide the coaptation for continence at
rest and during increase in the abdominal pressure [9].
Both the bladder neck and the urethra are normally maintained
in a high retropubic position relative to the more dependent bladder
base, creating a valvular effect. Furthermore, intra-abdominal forces
are directly transmitted to both bladder and proximal urethra.
It increases its resistance and promotes coaptation (pressure
transmission hypothesis) [9]. De Lancey proposed the “hammock
hypothesis” that abdominal pressure transmitted through the
proximal urethra presses the anterior wall against the posterior wall.
The posterior wall remains rigid if there is adequate pelvic support
from muscle and connective tissues [10]. After anterior pelvic
exenteration and excision of the whole vagina down just to below the
bladder neck, good continent status is reported. However, most even
all autonomic nerve supply is damaged [7].
Complete removal of the bladder neck with transaction of the
proximal urethra just below the vesicourethral junction is safe
because continence is maintained mainly by EUS. Therefore, with
proper minimal dissection anteriorly along the pelvic floor to protect
the pelvic floor musculature and the pudendal nerve to preserve
the nerve supply to the EUS, postoperative continence should be
maintained [11].
Patient's selection for orthotopic neobladder
Selection of female patients for ONB depends on three important
factors. First is the oncological factor. Presence of bladder neck
involvement, multifocal tumors, diffuse carcinoma in situ, clinically
evident lymph node and distant metastasis are contraindication for
USRC and ONB [12]. Second is the functional factor. Patients should
be fully continent before surgery determined by proper history
taking, pelvic examination, cystoscopy and urethral pressure profile
[13]. Stenzl and Holtl had proposed specific criteria for predicting
lower possibility of regaining postoperative continence in female.
It included history of stress incontinence of grade II or more due
to an incompetent sphincter, a marked urethral hypermobility or
a maximal resting pressure in the UPP of less than 30 cm H2O [7].
Also, good performance status is important as they need certain
strength for continence training in the early postoperative period.
Patients with ONB learn to void through simultaneous relaxation of
the pelvic floor muscles and rising of intra-abdominal pressure with a
valsalva maneuver. Third factor is the patients' motivation to undergo
this surgery and accepting the related complication especially using
Intermittent Self Catheterization (ISC) if Chronic Urine Retention
(CUR) developed [7].
Voiding and continence outcome after RC and ONB
The main goal of ONB is to approximate the normal bladder
function. The patient can void intentionally volitionally though
the normal urethra. This to restore the preoperative function and
maintain Health Related Quality Of Life (HRQOL). This clinically is
achieved when neobladder allows volitional voiding four to six times
daily (every 3 to 4 hours) with a capacity range of 400 to 500 ml of
urine at low pressures [14].
Continence is influenced by accommodation of reservoir
characteristics (large capacity, low pressure) as well as outlet resistance
(continence mechanism). Ideal reservoir should achieve ideal
functional, social, technical and safety criteria. From the functional
point of view, it should be of adequate capacity to achieve accepted
frequency of urine evacuation, durability, dryness and control
without urge or stress. In addition, from the social point of view, it
should preserve body image and provide day and night Continence.
Furthermore, technically it should be feasible, with no need of
foreign material, versatile to cope with different indications, allow
surveillance of the upper tract as well as minimal need of revisional
surgeries. Also, regarding safety of the reservoir, it is a critical point
to be reviewed thoroughly before decision making. It should achieve
safe resection from the digestive tract to minimize mal-absorption
and diarrhea with less metabolic consequences. The reservoir should
be Safe on the upper tract, with minimal risk of malignancies and
with easy revisional surgery whenever indicated [15].
Continence problems
Urinary incontinence after ONB may develop due to pouch
factors including: reduced capacity, high pressure, urinary tract
infection, or presence of pouch stones. Also, loss of afferent input
from the detrusor muscles to the central nervous system is thought
to account, in part, for the worse continence at night in patients
with an orthotopic substitute. Disturbance in the integrity of the
external sphincter is the other factor that contributes to incontinence
post orthotopic diversion. One contributing factor is thought to
be worsening urethral sphincter function with age. Furthermore,
decreased urethral sensitivity has been proposed as a potential factor
contributing to urinary incontinence after radical cystectomy and
orthotopic diversion [16].
Urodynamic evaluation of women with nocturnal incontinence
post USRC and ONB revealed presence of pouch hyperactivity in 48%
and reduced Maximal Urethral Closure Pressure (MUCP) and leak
point pressure in (16%) of patients [17]. Recently, Gross et al. [13]
reported that women with postoperative incontinence have lower
functional urethral length (median 24mm vs. 32mm in continent
women, p= <0.001) and lower postoperative urethral closure pressure
(35cm H2O vs. 56 cm H2O, p= <0.001) at rest in comparison to
continent women. Also, uterus preservation and trial of nerve sparing
improved postoperative continence status [18].
The reported daytime continence after ONB in women ranged
from 57% to 90%, while nighttime continence ranged from27-86%.
(Table 1).
Voiding problems
After ONB in women, not all women can void spontaneously. A
considerable proportion of women develop Chronic Urine Retention
(CUR). The incidence ranged between 12 to 58% of cases. (Table 1)
Chronic Urine Retention (CUR) is defined as persistent inability to
completely empty the pouch which results in elevated post voiding
residual urine. According to our protocol, we advised patients to start
ISC when post voiding residual urine is greater than 150 ml or more
than 20% of the maximum reservoir capacity [19-25].
Till now the exact mechanism and cause of CUR after USRC and
ONB is a matter of debate. There are two prevailing theories. The
first theory explained it by autonomic denervation either completely
causing a tonic proximal urethra that collapse during voiding causing
obstruction or partially with sympathetic sprouting to denervated
smooth muscle sphincter causing obstruction. They recommended
nerve sparing cystectomy to reduce the incidence of CUR [13,26].
However, denervation and urethral transection in dogs resulted in
reduction of the pressure in the proximal urethra by 50% and did not
affect the mid- or distal urethra and there was no detected fibrosis or
collapse in the proximal urethra on cystoscopy [27].
The other theory postulated that the cause of CUR is a mechanical
cause due to significant descent of the pouch and posterior pouch
sagging with herniation through anterior vaginal wall during
straining. This is based on the result of dynamic MRI and urodynamic
investigation of women with CUR post USRC and ONB. The authors
recommended mechanical modification to provide back support to
the pouch [19].
Impact of continence problem on HRQOL
The advances in the field of UD were to improve patients'
HRQOL. Orthotopic neobladder (ONB) was developed to deal with
these concerns, enabling volitional voiding through the urethra and
providing the additional advantage that a cutaneous stoma with the
need for an external appliance is avoided [12].
Although many studies have discussed the impact of RC and
UD on HRQOL, enough data in women is still lacking. Many
studies reported no advantage of ONB over other form of diversion
regarding patients' HRQOL [28-30]. On the other hand, Hobisch et
al. [31] reported that ONB patients had better all domains of HRQOL
in comparison to Ileal Conduit (IC) patients. Also, Philip et al. [32]
reported more active life style and better HRQOL in ONB patients.
However, the results of these studies needs proper interpretation
due to small patients number and inclusion of both male and female
patients. Only one recent study by Gacci et al. [28], compared HRQOL
in women after different types of diversion and concluded that there
was no statistically significant difference between IC and ONB.
Urinary troubles after UD have a significant impact on patients'
HRQOL. Thulin et al. [33] reported that nocturnal incontinence
affected patients' sleep and decreased their HRQOL than other
diversion groups. This resulted in lower self-assessed HRQOL,
physical health and energy level [33]. We compared the HRQOL of
74 women after RC and ONB with age matched normal group. There
was statistically significantly lower all domains of HRQOL among
the study group than the control group. The study group included
18 completely continent patients, 29 with nocturnal incontinence
and 27 with chronic urinary retention. Completely continent women
were comparable with those with chronic urinary retention. Women
with night-time incontinence had a significantly worse HRQOL both
groups [12].
Conclusion
Nerve sparing radical cystectomy and ONB has become the standard of care for selected women with muscle invasive bladder cancer. However, it is associated with significant incidence of continence and voiding problem that adversely affect patients' HRQOL. Proper patients' evaluation and identification of possible risk factors is mandatory before decision making in order to reduce the possible risk of continence trouble.
References
- Nagele U, Kuczyk M, Anastasiadis AG, Sievert KD, Seibold J, Stenzl A. Radical cystectomy and orthotopic bladder replacement in females. Eur Urol. 2006; 50: 249-257.
- Simon DW, Chang VS, Stein J P. Pathologic Guidelines for Orthotopic Urinary Diversion in Women with Bladder Cancer: A review of the literatures. Rev Urol. 2006; 8: 54-60.
- Ali-EL-Dein B, Shabaan AA, Abu-Eideh RH, El-Azab M, Ashamallah A, Ghoneim MA. Surgical complications following radical cystectomy and orthotopic neobladder in women. J Urol. 2008; 180: 206-210.
- Hautmann RE. Which patient with transitional cell carcinoma of the bladder or prostatic urethra are candidate for an orthotopic neobladder? Curr Urol Rep. 2000; 1: 173-17 6.
- Skinner EC, Skinner DG, Stein JP. Orthotopic urinary diversion. In: Wein AJ, Kavoussi LR, Partin AW, Novick AC, Peters CA (editor): Campbell-Walsh Urology. 2012.
- Hautmann RE, Abol-Enein H, Hafez K. Urinary diversion. Urol. 2007; 69: 17-49.
- Stenzl A, Höltl L. Orthotopic bladder reconstruction in women--what we have learned over the last decade. Crit Rev Oncol Hematol. 2003; 47: 147-154.
- Colleselli K, Stenzl A, Eder R, Strasser H, Poisel S, Bartsch G. The female urethral sphincter: A morphological and topographical study. J Urol. 1998; 160: 49-54.
- Rosenbulm N, Eliber KS, Rodriguez LV, Raz S, Vasavada SP, Appel RA, et al. Anatomy of pelvic support. In: (editor): female urology, urogynaecology and voiding dysfunction. 2005.
- De Lancy JO. structural aspects of female continence mechanism: the hammock hypothesis. Am J Obstet Gynaecol. 1994; 170: 1713-1723.
- Stein JP, Giensberg DA, Skinner DG. Indication and technique of orthotopic neobladder in women. Urol Clin North Am. 2002; 29: 725-734.
- Zahran MH, El-Hefnawy AS, Zidan EM, El-Bilsha MA, Taha DE, Ali-El- Dein B. Health-related quality of life after radical cystectomy and neobladder reconstruction in women: impact of voiding and continence status. Int J Urol. 2014; 21: 887-892.
- Gross T, Meierhans Ruf SD, Meissner C, Ochsner K, Studer UE. Orthotopic ileal bladder substitution in women: factors influencing urinary incontinence and hypercontinence. Eur Urol. 2015; 68: 664–671.
- Steers WD. Voiding dysfunction in the orthotopic neobladder. World J Urol. 2000; 18: 330-333.
- Abol-Enein H, Salem M, Mosbah A. Continent cutaneous ileal pouch using the serous lined extramural valves. The Mansoura experience in more than 100 patients. J Urol. 2004; 172: 588–591.
- Hugonnet CL, Danuser H, Springer JP, Studer UE. Decreased sensitivity in the membranous urethra after orthotopic ileal bladder substitution. J Urol. 1999; 161: 418-421.
- Ali-El-Dein A, El-Hefnawy A, Zahran M, Shaaban AA, Ghoneim MA. Urodynamic characterization of voiding and continence problems after orthotopic neobladder in women. J Urol. 2011; 185: e458.
- Stenzl A, Jarolim L, Coloby P, Golia S, Bartsch G, Babjuk M, et al. Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors. Cancer. 2001; 92: 1864-1871.
- Ali-El-Dein B, Gomha M, Ghoneim MA. Critical evaluation of the problem of chronic urinary retention after orthotopic bladder substitution in women. J Urol. 2002; 168: 587-592.
- Lee CT, Hafez KS, Sheffield JH, Joshi DP, Montie JE. Orthotopic bladder substitution in women: nontraditional applications. J Urol. 2004; 171: 1585-1588.
- Granberg CF, Boorjian SA, Crispen PL, Tollefson MK, Farmer SA, Frank I, et al. Functional and oncological outcomes after orthotopic neobladder reconstruction in women. BJU Int. 2008; 102: 1551-1555.
- Stein JP, Penson, DF, Lee C, Cai J, Miranda G, Skinner DG. Long-Term Oncological Outcomes in Women Undergoing Radical Cystectomy and Orthotopic Diversion for Bladder Cancer. J Urol. 2009; 181: 2052-2059.
- Yang G, Whitson JM, Breyer BM, Konety BR, Carol PR. Oncological and Functional Outcomes of Radical Cystectomy and Orthotopic Bladder Replacement in Women Urol. 2011; 77: 878–883.
- Anderson CB, Cookson MS, Chang SS, Clark PE, Smith JA Jr, Kaufman MR. Voiding function in women with orthotopic neobladder urinary diversion. J Urol. 2012; 188: 200-204.
- Jentzmik F, Schrader AJ, de Petriconi R, Hefty R, Mueller J, Doetterl J, et al. The ileal neobladder in female patients with bladder cancer: long-term clinical, functional, and oncological outcome. World J Urol. 2012; 30: 733-739.
- Stenzl A, Colleselli K, Bartsch G. Update of urethra-sparing approaches in cystectomy in women. World J Urol. 1997; 15: 134-138.
- Ali-El-Dein B, Ghoneim MA. Effects of selective autonomic and pudendal denervation on the urethral function and development of retention in female dogs. J Urol. 2001; 166: 1549–1554.
- Gacci M, Saleh O, Cai T, Gore JL, D'Elia C, Minervini A, et al. Quality of life in women undergoing urinary diversion for bladder cancer: results of a multicenter study among long-term disease-free survivors. Health Qual Life Outcomes. 2013; 11: 43.
- Fujisawa M, Isotani S, Gotoh A, Okada H, Arakawa S, Kamidono S. Health-related quality of life with orthotopic neobladder versus ileal conduit according to the SF-36 survey. Urology. 2010; 55: 862-865.
- Hedgepeth RC, Gilbert SM, He C, Lee CT, Wood DP Jr. Body image and bladder cancer specific quality of life in patients with ileal conduit and neobladder urinary diversions. Urology. 2010; 76: 671-675.
- Hobisch A, Tosun K, Kinzl J, Kemmler G, Bartsch G, Höltl L. Quality of life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion. World J Urol. 2000; 18: 338-344.
- Philip J, Manikandan R, Venugopal S, Desouza J, Javlé PM. Orthotopic neobladder versus ileal conduit urinary diversion after cystectomy—a quality-of-life based comparison. Ann R Coll Surg Engl 209; 91: 565-569.
- Thulin H, Kreicbergs U, Wijkström H, Steineck G, Henningsohn L. Sleep disturbances decrease self-assessed quality of life in individuals who have undergone cystectomy. J Urol. 2010; 184: 198-202.